Further Outpatient Care

Further Inpatient Care

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No inpatient care is indicated for thoracic outlet syndrome, unless the patient is treated surgically.

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Deterrence

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In some cases, thoracic outlet syndrome (TOS) may be preventable. Proper flexibility and strength, along with good posture, are very important for individuals who are at risk for developing this condition. One should avoid stressful positions and limit the amount of time completing repetitive or overhead activities. A workstation evaluation may be very beneficial to identify potential causes of TOS. If repetitive or overhead activities are required at work, one should take frequent rest breaks, change positions whenever possible, and ensure a proper workstation setup. Avoidance of working with outstretched arms and heavy lifting or carrying also can help to avoid developing TOS symptoms.

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Complications

Complications that may develop in individuals with thoracic outlet syndrome include the following:

Chronic pain

Disability and loss of functional ability with the upper extremity

Depression

Neurologic deficit

Thrombosis

Ischemia

Pseudoaneurysm

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Prognosis

Prognosis is generally good for most cases of thoracic outlet syndrome (TOS), unless it is severe and requires surgery. Some patients may develop chronic pain and disability that can be complicated by legal and psychological issues. Recognition and prompt treatment of such psychological and disability issues can limit the complications.

Most patients obtain relief of paresthesias and numbness with a return of strength or activity tolerance; however, recurrence is common, especially with resumption of the activity that led to symptom onset. Posture correction and strengthening usually is necessary to maintain improvement.

In a study by Likes et al of patients with TOS, 100 out of 271 patients (37%) who were initially managed with TOS-specific physical therapy improved with this treatment alone.
[19]

In a study of competitive athletes with TOS, however, only mild to modest symptom improvement was seen in those with neurogenic TOS who were initially treated with TOS-specific physical therapy. Consequently, 67% of the neurogenic TOS patients went on to be treated with supraclavicular first rib resection and brachial plexus neurolysis. Nonetheless, of the 81% of the group with neurogenic TOS who were able to return to full competitive athletics, 32% did so after management only with physical therapy.
[20]

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Patient Education

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Educating patients about the causes or perpetuating factors involved in thoracic outlet syndrome is essential. Offer training to minimize the likelihood of recurrence.

Proper use of keyboards and adjustment of workstation ergonomics are useful. Specific techniques for exercise and motivation are necessary. Appropriate management of stress and depression also are helpful.

Stretching technique for the pectoralis minor muscle. Left: The patient has taken the slack out of the muscle. Center: He then rotates the body away from the side being stretched, increasing traction. Right: Maximum rotation and stretch effect are achieved slowly. Image courtesy of The Journal of the American Osteopathic Association

Sagittal plane posture of patient with thoracic outlet syndrome before (left) and after (right) treatment. Notice the release of the pelvis that occurred with the reduction in hyperlordosis, which allowed the shoulder girdle to drop back and open the thoracic outlet. Image courtesy of The Journal of the American Osteopathic Association

Myofascial release technique for the scalene muscles. Left: Side-lying approach. Right/top: Supine approach with pillow under thorax. Right/bottom: Supine approach with head extended off the table and supported by the operator's knees. Image courtesy of The Journal of the American Osteopathic Association

Stretching technique for the scalene (anterior and middle) muscles. Left: The arm on the side to be stretched is secured down (hooked under the seat) to allow more control and effective stretch. Center: The opposite hand wraps partially around the head for good control to assist with the stretch. Right: After proceeding as far as tolerated, the patient leans the whole trunk away from the side being stretched, creating additional traction (downward) on the muscle by the arm that is secured. Image courtesy of The Journal of the American Osteopathic Association

Algorithm for the treatment of nonprogressive thoracic outlet syndrome (TOS). Anti-inflammatory medication, muscle relaxants, and activity modifications all are used as indicated and tolerated in all cases. Values for very severe TOS are greater than those for severe TOS, and the patient probably should be referred for surgical evaluation.